Blind spot in brain imaging
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The document outlines various radiological findings in brain imaging, presenting cases of acute/subacute conditions including subarachnoid hemorrhage, infarcts, and intracranial thrombosis, which were often initially misinterpreted or missed by junior radiologists. It emphasizes the importance of careful observation in detecting subtle lesions such as tumors and inflections associated with cranial nerves, and reports on anomalies like Chiari malformation and complicated sinusitis. Overall, the findings underscore the need for improved diagnostic training to prevent oversight of critical neurological conditions.
Blind spot in brain imaging
- 1. Normal looking abnormal brain (Review areas in routine practice) Poster no. C-2347/ECR 2019 dx.doi.org/10.26044/ecr2019/C-2347 P. Hota, H. C. Chadaga, S. Patwari, S. Kanumukullakshminarayana; Bangalore/IN
- 3. Findings: NCCT axial images of brain demonstrate subtle linear hyperdensity in the right (green arrow in A) and left parietal sulci (red arrow in B) suggestive of acute subarachnoid haemorrhage(SAH). Minimal intraventricular hemorrhage also seen in the right occipital horn (blue arrow in C).
- 4. Axial CT image of brain demonstrate small isodense subacute subdural hemorrhage over right temporal convexity which can be missed by an untrained eye (A). On subdural window hemorrhage can be better appreciated (orange arrows in B).
- 5. Non-contrast CT images (A & B) of brain demonstrates isodense subdural collect
- 6. Non-contract CT axial images of brain demonstrate multiple punctate hemorrhagic
- 7. Axial bone window CT image of head shows subtle left nasal bone fracture (blue arrow in A) and thin linear lucent line in the right supra orbital margin extending along the orbital roof suggestive of fracture (red arrows in B). Subtle superficial soft tissue swelling seen over right orbit (yellow arrow in C).
- 8. Axial bone window CT image demonstrates comminuted fracture of left carotid canal (red arrow in A) and mildly displaced fracture of lateral wall of right carotid canal (green arrow in A). Also there are longitudinal fractures of bilateral temporal bones with hemomastoid. Follow up non-contrast CT brain (performed after 3 days) demonstrates multiple varying sized hypo dense areas in bilateral cerebral hemispheres suggestive of infarcts.
- 9. Coronal CT images showing fracture of right orbital floor (blue arrow in A) and fra
- 10. Axial CT images in bone window showing longitudinal fracture of right temporal bone (A) and transverse fracture of left temporal bone(B).
- 11. Axial MR images of brain showing subtle hyperintensity in the left insular cortex on DWI image (A) with corresponding hypointensity on ADC image (B) suggesting diffusion restriction and suggestive of hyper acute left MCA territory infarct. Corresponding FLAIR image (C) demonstrates no abnormality in left insular cortex (Normal looking !).
- 12. DWI/ADC axial images of brain showing punctate diffusion restricting focus in mid brain on left side (red arrows in B and C)suggestive of infarct. Corresponding CT image demonstrates no abnormality (A, Normal looking !)
- 13. Axial MR images of brain at the level of medulla showing small hyperintense focus in the right lateral portion of medulla on DWI (red arrow in A) and T2w (yellow arrow in B) images, suggestive of lateral medullary infarct (ADC image not shown). Axial DWI image of brain demonstrates small acute infarct ( blue arrow in C) demonstrates small acute infarct in the para-sagittal portion of right frontal lobe (This finding was missed by reporting resident).
- 14. Axial non-contrast CT ( A) demonstrate hyper dense left MCA (red arrow in A: MCA dot sign and yellow arrows in B: Dense MCA sign) suggestive of thrombosis. It was missed by reporting junior radiologist at the time of initial presentation. Large MCA territory infarct was seen on MRI (Not shown).
- 15. Axial noncontrast CT image of brain shows loss of definition of the gray-white matter interface in the lateral margin of the left insular cortex (“Loss of insular ribbon") suggestive of hyper acute infarct. Note to be made of normal definition of gray – white interface in right insular cortex.
- 16. CT axial image of brain demonstrate loss of delineation of the left basal ganglia suggestive of acute MCA territory infarct.
- 17. FLAIR and T2W images of brain demonstrate loss of flow void in right transverse sinus (yellow arrows in A and B). GRE image of brain demonstrating blooming lines in right transverse sinus (red arrow in C). TOF MRV image demonstrate loss of flow related enhancement (green arrow in D). Features suggestive of dural venous thrombosis. Brain parenchyma showed no abnormality.
- 18. Small T1w hyperintense lesion arising from the right tectal plate which is supressing on T1w fat suppression sequence, suggestive of tectal lipoma. On close observation T2w hyperintense lesion seen in the same location.
- 19. : Axial and coronal CT images in bone window demonstrate destructive changes around the left jugular canal (red arrows in A and B). Post contrast CT axial image demonstrates markedly enhancing mass (green arrow in C) in the left jugular canal suggestive of paraganglioma like glomus jugulare
- 20. Small extra-axial cystic lesion in the inferior aspect of the right medial temporal lobe showing central fluid intensity (red arrows in A, B, C, D) and mild peripheral enhancement (green arrow in E). This was a case of Trigeminal cystic Schwannoma. Such lesions can be potentially missed.
- 21. Axial and parasagittal CT images demonstrates well-delineated mildly hypodense mass lesion in the left Meckel's cave expanding the foramen ovale and extending to the masticator space. This was a case of left trigeminal nerve schwannoma. Lesion is subtle on axial images (yellow arrows in A) but very much evident on parasagittal images (red arrows in B). This lesion was not mentioned by reporting radiologist.
- 22. the left frontal lobe suggestive of small convexity meningioma
- 23. CT of brain showing small cyst with central hyperdensity (scolex) in the left lateral rectus muscle in a known case of disseminated neurocysticercosis. This lesion was missed by the reporting radiologist.
- 24. small soft tissue dense lesion in the right middle ear cavity with subtle erosions of adjacent antero-lateral margin of jugular foramen (yellow arrow in A and orange arrow in C). Contrast enhanced axial T1w MR image demonstrates heterogeneous marked enhancement of the lesion (red arrow in B). Features are suggestive of glomus tympanicum.
- 25. soft tissue enhancing mass encasing the distal cisternal portion of right vesibulocochlear - facial nerve complex within the internal auditory canal. This was a case of vestibular schwannoma.
- 26. An B-abnormal T1w and T2w hypo intense signal changes in the clivus (yellow arrows in A and B). These findings are not reported by the reporting radiologist. The pain was attributed to cervical spine degenerative changes. C-E: Patient came after 2 months with persistent symptoms of neck pain, low grade fever and right facial nerve palsy. T1w post contrast MRI sagittal and axial images demonstrate heterogeneously enhancing abnormal soft tissue in pharyngeal mucosal space adjacent to clivus (red arrows in C and D). There is heterogeneous enhancement of the clivus in association with replacement of normal hyperintense fatty marrow, features are consistent with skull base osteomyelitis. Corresponding sagittal CT image demonstrates patchy sclerosis in the clivus (orange arrow in E).
- 27. Unenhanced T1W axial and FLAIR images show normal appearing bilateral optic nerves ( A and C). There is mild enhancement of optic nerves on post contrast T1w images which better appreciated on post contrast FLAIR images ( red arrows in D). This was case of Neuromyelitis optica.
- 28. ced axial FLAIR image showing no abnormality (B). Post contrast T2W FLAIR axial image showing abnorm
- 29. geminal nerve and its nucleus on FLAIR and CISS images (orange arrows in A and B). Post contrast T1w i
- 30. ment (arrows). (D) Sagittal non contrast T1w image shows venous distension sign (curved arrow) with infer
- 31. Axial T2w images of brain at the level of orbits demonstrate prominent bilateral peri-optic CSF spaces (red arrows in A) and flattening of the posterior sclera (arrows in B). T1w sagittal image demonstrates partial empty sella (C) and MRV image demonstrates focal stenosis of right distal transverse sinus. Left transverse and sigmoid sinuses are hypoplastic. Features are suggestive of intracranial hypertension.
- 32. Sagittal non-enhanced T1w MR image shows loss of normal posterior pituitary bright spot (blue arrow in A). Sagittal post contrast T1w MR image shows enhancement of the thickened infundibulum (blue arrow in B). Features are suggestive of lymphocytic infundibulo-neurohypophysitis. Often such a finding can be subtle and missed
- 33. Axial head CT image shows a subtle hyperdensity in the left temporo-pareital sulci (red arrows in A) . Axial FLAIR MR image shows a sulcal hyperintensity (orange arrows in B) in the left parieto-occipital sulci, consistent with Nonaneurysmal SAH. This was a case of Postpartum cerebral angiopathy.
- 34. s abutting the temporal horn (red arrows in A and B). Rest of the sequences showed no significant abnorm
- 35. Sagittal T1w sections of brain demonstrate herniation of cerebral tonsils through the foramen magnum (dark orange arrows) and there is syrinx in the cervical cord at the level of C5 and C6 vertebral levels (light orange arrows. Features are suggestive of Chiari 1 malformation with syrinx. This case was reported as normal study by a junior radiologist
- 36. Coronal T2w image of the brain demonstrates epidural collection along the anterior skull base adjacent to sphenoid sinuses. Diffuse mucosal thickening seen in sphenoid sinuses. Postcontrast T1w image demonstrates thick dural enhancement (green arrow in B) adjacent to the collection. Sagittal and coronal CT images of demonstrates bony erosions along the walls of sphenoid sinuses. Features of suggestive of complicated sinusitis with anterior skull base epidural abscess.
- 37. Midsagittal section of MRI Brain showing "BLIND SPOTS"
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